Hernias and Abdominal Wall Defects in ChildrenTarek A. HassanFRCS, MDProf. of Pediatric Surgery

Prof. Tarek Hassan

Prof. Tarek Hassan*Definition of Hernia Protrusion of a sac of peritoneum together with preperitoneal fat or an organ through a congenital or acquired defect in the muscles of the abdominal wall through which they do not normally pass

Prof. Tarek Hassan

Prof. Tarek Hassan*Classification of Hernias in ChildrenInguinal Hernia Umbilical Hernia Diaphragmatic Hernia Incisional Hernia Rare Hernias : Epigastric, Lumber, Femoral and Spigellian Other abdominal wall defects: Omphalocele, Gastroschisis, Bladder extrophy

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Prof. Tarek Hassan*PROCESSUS VAGINALISCloses at 6 months of age .Doesnt mean inguinal hernia Potential space

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Prof. Tarek Hassan*INGUINAL HERNIA In MalesFailure of obliterationInguinal bulge May be the 1st.time irreducable

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Prof. Tarek Hassan*INGUINAL HERNIA In MalesInguinoscrotalReduction is difficult .Sliding viscera

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Prof. Tarek Hassan*Inguinal Hernia In MalesType: Indirect Content : intestine, omentum Bilateral < 50% Complications: irreducibility, testicular atrophy, strangulation, obstruction, infection Operation : Unilateral herniotomy ,once detectedContra lateral exploration ??

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Prof. Tarek Hassan*Inguinal Hernia In Males

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Prof. Tarek Hassan*Inguinal Hernia In Males (cont.)

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Prof. Tarek Hassan*Inguinal Hernia In FemalesType : Indirect Content : Ovary Bilateral > 50% Complication : Ovarian affection Operation : Herniotomy once detectedContra lateral exploration ??

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Prof. Tarek Hassan*Inguinal Hernia In Females

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Prof. Tarek Hassan*CONGENITAL HYDROCELEHigh incidence in newborns .Conservative till 9-12 months .Indication of surgery : *Increase in size *With hernia *Of hernial sac

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Prof. Tarek Hassan*ENCYSTED HYDROCELE OF THE CORDEncysted fluid Difficult dif. diagnosis from irred. Hernia .Follow up for the younger age group.

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Prof. Tarek Hassan*DEVELOPMENT OF A NORMAL UMBILICUS6 weeks embryoNormal umbilicus

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Prof. Tarek Hassan*UMBILICAL HERNIAUmbilical defect covered by skin and contains intestine.Incidence: 1 every 6 newborn. 9 times more in blackSpontaneous closure is the rule.Complications are rare.

Prof. Tarek Hassan

Prof. Tarek Hassan*UMBILICAL HERNIAHerniotomy & Anatomical repair is indicated if it persists beyond 2 to 3 yrs *Defect< 1 cm-------6 yrs *Defect 1-2 cm------4 yrs *Defect >2 cm-------2yrsRole of truss is uncertain.D.D. : Para-umbilical hernia.

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Prof. Tarek Hassan*Congenital Diaphragmatic Hernias

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Prof. Tarek Hassan*Congenital Diaphragmatic HerniasCong. diaphragmatic hernia (Bochdalek) Cong. hiatal hernia Parasternal hernia (Morgagni) Eventration of the diaphragm. Traumatic diaphragmatic hernia

Prof. Tarek Hassan

Prof. Tarek Hassan*CONGENITAL DIAPHRAGMATIC HERNIA (Bochdalek)Due to persistent pleuroperitoneal canal90% are on the left side Associated pulmonary hypoplasia is the most important factor determining survivalAntenatal diagnosis by U.S.

Prof. Tarek Hassan

Prof. Tarek Hassan*Presentation: dyspnea, cyanosis, dextrocardia, diminished chest movements, scaphoid abdomen, intestinal sounds in the chest.CONGENITAL DIAPHRAGMATIC HERNIA (Bochdalek)

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Prof. Tarek Hassan*Diagnosis: X-ray chest & abdomenCONGENITAL DIAPHRAGMATIC HERNIA (Bochdalek)

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Prof. Tarek Hassan*Treatment: Paralyzed, ventilated, and stabilized for 24-48 hrs Reduction of the contents and closure of the defect through a trans. abdominal incision. Mortality: 50% depending on the degree of lung hypoplasiaCONGENITAL DIAPHRAGMATIC HERNIA (Bochdalek)

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Prof. Tarek Hassan*CONGENITAL DIAPHRAGMATIC HERNIA (Bochdalek)

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Prof. Tarek Hassan*CONGENITAL HIATAL HERNIAUsually sliding rarely para-oesophageal Associated with gastro-oesophageal reflux

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Prof. Tarek Hassan*

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Prof. Tarek Hassan*CONGENITAL HIATAL HERNIA&Gastro-oesophageal refluxPresentation: Vomiting, failure to thrive, chest infection, dyspnea Diagnosis: Barium meal, Endoscopy , PH metry, Manometry Complications: Oesoph. Ulcers , strictures, hematemesis, shortening, Barret oesophagus

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Prof. Tarek Hassan*CONGENITAL HIATAL HERNIA Sliding

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Prof. Tarek Hassan*CONGENITAL HIATAL HERNIA Para-oesophageal

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Prof. Tarek Hassan*CONGENITAL HIATAL HERNIA& Gastro-oesophageal refluxMedical ttt for reflux : Positioning, Anti acids, H2 blokers , Proton pump inhibitorIndications for Surgical ttt : *Failure of medical ttt *Associated hernia *Development of complicationsSurgery: Nissen Fundoplication

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Prof. Tarek Hassan*Parasternal hernia (Morgagni)

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Prof. Tarek Hassan*Eventration of the diaphragm

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Prof. Tarek Hassan*OMPHALOCELEUmbilical defect covered by amniotic membrane and contains intestine.Major: diameter more than 5cm and contains liver.Minor: diameter less than 5cm.

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Prof. Tarek Hassan*OMPHALOCELECongenital anomalies are common especially chromosomal and cardiac.

Antenatal diagnosis: U.S.

Preoperative management.

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Prof. Tarek Hassan*OMPHALOCELE Primary closure

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Prof. Tarek Hassan*OMPHALOCELE Gradual reduction & delayed primary closure

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Prof. Tarek Hassan*OMPHALOCELE Non-operative treatment

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Prof. Tarek Hassan*GASTROSCHISISAbdominal wall defect 2 to 4cm in diameter and is lateral (to the right) of the umbilical cord. It has no sac.Intestine is thick and oedematous.Malrotation is usually present

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Prof. Tarek Hassan*GASTROSCHISISAssociated congenital anomalies are rare.

Needs emergency surgery: Primary closure. Gradual reduction& delayed closure.

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Prof. Tarek Hassan*EXTROPHY OF THE URINARY BLADDER

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Prof. Tarek Hassan*CLOACAL EXTROPHY

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Prof. Tarek Hassan*PRUNE BELLY SYNDROMAbdominal muscle deficiency Dilated urinary system Bilateral undescended testes

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Prof. Tarek Hassan*THANK YOU

Prof. Tarek Hassan